Maternity Services

Part of the debate – in the House of Lords at 7:26 pm on 15th January 2003.

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Photo of Lord Patel Lord Patel Crossbench 7:26 pm, 15th January 2003

My Lords, I, too, should like to thank the noble Baroness, Lady Cumberlege, for initiating this debate. There can be little doubt about her commitment to improving maternity services. Her report, Changing Childbirth, familiarly known as the Cumberlege report, may not have been universally well received, but it certainly raised the profile of maternity services and changed the thinking from looking at maternity services from the profession's point of view to putting mothers and babies centre stage.

Irrespective of any changes in the services introduced now or in the future, we should not go backwards. We run the risk of doing so with some of the recent reconfiguration of services. Frankly, our maternity services are in a mess. However, there is still time to stop the situation worsening if there is recognition from the centre that something needs to be done.

Much of today's debate is about the reconfiguration of maternity services that is going on ad hoc—for example, as a response to the pressure of reduction in junior doctors' hours, shortage of staff, lack of resources, cost saving initiatives, falling birth rate, smaller units, and so forth.

In an attempt to cope with the pressures, managers and clinicians embrace changes that do not serve the needs of mothers and their babies. Amalgamation of maternity units into bigger units, without capacity building in the number of staff and facilities, leads to further reduction in the quality of care delivered, and standards fall. Evidence gathered from midwives, the National Childbirth Trust and the Royal College of Obstetricians and Gynaecologists demonstrates that.

Every time there is a crisis of confidence in maternity services an inquiry is held. It happened with the Peel report and again in 1992 when the House of Commons Health Select Committee conducted an inquiry into maternity services—to which I was one of the advisers. That led to the then government report, Changing Childbirth.

It was announced yesterday that the Maternity Services Sub-committee of the House of Commons Health Select Committee is to start an inquiry focusing on variation in maternity services, data collection, staffing structures, caesarean section rates, and so forth. There are also other initiatives. We heard about the initiative from the National Institute for Clinical Excellence, which has commissioned guidelines on caesarean section following a national audit. I hope that the guidelines will define standards of care that women undergoing caesarean sections should expect, including who makes, and has the responsibility for, the decision to carry out a caesarean section.

I understand that in future there will be guidelines for antenatal care and screening in pregnancy. Other initiatives have already been mentioned—the workforce group on children's and maternity services, a department initiative report on criteria to be met when reconfiguring maternity services. The Secretary-General of the Royal College of Midwives and I, with the former Secretary of State, Frank Dobson, asked for that initiative report to be carried out. Neither of these reports is in the public domain. I wonder what the recommendations were that cannot be made public.

Another initiative set up by the Department of Health is the National Service Framework for Children's Services, but it will include a section for maternity services. Will the Minister say whether this section defines the framework for maternity services?

It all seems to be rather haphazard planning. What we need is a co-ordinated strategy, initiated by the Department of Health, together with maternity services, in the same league as our near-neighbours in Europe, or better.

We have a serious shortage of staff. All of the previous speakers have referred to this. We have a huge shortfall in the number of midwives, a profession that is key to delivering high-quality care to all mothers and their babies during both pregnancy and the post-partum period. We have a shortage of obstetricians, particularly of those who are able and willing to deliver hands-on care at all times of the day whenever women need their help.

The noble Baroness, Lady Perry of Southwark, eloquently described the problems and how they occurred, and I will not dwell on them again, but I am grateful to her for highlighting them. Apart from obstetrics being a more demanding specialty, obstetricians and gynaecologists may see the choice of taking one of the ever-expanding, sometimes esoteric, gynaecological sub-specialties as a better option. If so, there may be a need to look at the training and remuneration for obstetrics as distinct from gynaecology. The training of doctors and all health professionals should reflect the health needs of society. I hope that a new postgraduate medical education and training board, when established, will have the responsibility and authority to make sure that all training programmes reflect this.

I am pleased to see the current president and vice-president of the Royal College of Obstetricians and Gynaecologists, Professor Dunlop and Miss Mellows, attending this debate. I am sure that they and the college will look at ways to improve recruitment to obstetrics, for it is important that women who need care from obstetricians receive it from fully trained and competent doctors. Managers, also, should recognise the need to recruit more obstetricians.

My noble friend Lord Chan has already alluded to the problems with paediatrics and ethnic minorities. I simply concur.

Staffing is not the only issue. We have a lack of appropriate facilities. This leads to an early discharge of mothers and babies from maternity units. It could affect rates of breast feeding and confidence building, particularly in first-time mothers. We have examples of women in labour, sometimes with problems identified in the antenatal period, being asked to stay at home until a bed is found somewhere, risking both themselves and their babies.

In terms of outputs we do not feature in the top league. While our perinatal mortality is not the worst in the developed world, it is well down the league table. We have not seen a reduction in the unexplained antenatal still birth rate for more than a decade. We have the second-highest rate of low-birth weight babies in the developed world, second only to the United States of America.

We have a high a premature birth rate. Now I know that social deprivation is an important factor for poor outcomes for mother and baby. Therefore, it is even more important that our services can deliver care to these at-risk mothers. Our data collection system is inadequate and we are not able to compare outcomes related to different models of care in the whole population.

We have a rising caesarean section rate. The noble Baroness, Lady Cumberlege, referred to this. It will keep on rising until we have a service that provides one-to-one support to all women in labour by midwives and care by trained and competent obstetricians for those women who are at risk of requiring caesarean section. Both midwife and obstetric support is essential if we are to reduce caesarean section rates.

We also have one of the highest rates of litigation: 50 per cent of all medical litigation is related to pregnancy and child birth. It is estimated that the cost of settlements of currently pending cases may well be in the region of £2 billion to the NHS. I understand that the department has on-going initiatives through risk management and clinical governance to reduce the level of litigation in obstetrics.

I return to my theme of haphazard, uncoordinated stabs at tackling the problems. Does the Minister not agree that it would be better now to produce a Department of Health- sponsored maternity services framework, with clear targets for implementation and monitoring, which the future commission for health auditing inspectorate could monitor? Both Scotland and Northern Ireland have done so and I would commend to the Minister the Scottish framework and implementation documents.

I agree that the current configuration of maternity services is not sustainable for all the reasons mentioned earlier. We need to develop services which recognise this, but which also recognise that the potential of all professionals involved in caring for mother and baby needs to be harnessed in a co-ordinated way, working across boundaries, while at the same time they retain their own professionalism.

This has implications for common, continuing education programmes. For this to happen, there needs to be committed and strong leadership from the centre and all health professions, with the focus on the needs of women and their babies.

It is not too late. Here is an opportunity for the Minister to give a lead and bring our maternity services into the 21st century, for a model service that we can all be proud of. He could start by establishing a framework for maternity services.

Finally, I did not declare an interest at the beginning. My credentials are all too clear. I feel passionately about the care of women in pregnancy and labour. For most of my life I have been an obstetrician.